1040 U.S.

Individual Income Tax Return 2019

Form Department of the Treasury—Internal Revenue Service (99)
OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying person is
one box.
a child but not your dependent. a
Your first name and middle initial Last name Your social security number
shawn E chavis 246-23-6504
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number
barbara C chavis 379-66-5351
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
Check here if you, or your spouse if filing
885 Lochaven Rd
jointly, want $3 to go to this fund.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Checking a box below will not change your
Waterford MI 48327-3913 tax or refund. You Spouse
Foreign country name Foreign province/state/county Foreign postal code If more than four dependents,
see instructions and  here a

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1955 Are blind Spouse: Was born before January 2, 1955 Is blind
Dependents (see instructions): (2) Social security number (3) Relationship to you (4)  if qualifies for (see instructions):
(1) First name Last name Child tax credit Credit for other dependents

lillian M chavis 377-29-2525 Daughter

lena R chavis 381-35-5259 Daughter

1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . . . 1 91,218.

2a Tax-exempt interest . . . . 2a b Taxable interest. Attach Sch. B if required 2b
3a Qualified dividends . . . . 3a b Ordinary dividends. Attach Sch. B if required 3b
Standard
Deduction for— 4a IRA distributions . . . . . 4a b Taxable amount . . . . . . 4b
• Single or Married
filing separately,
c Pensions and annuities . . . 4c d Taxable amount . . . . . . 4d
$12,200 5a Social security benefits . . . 5a b Taxable amount . . . . . . 5b
• Married filing
6 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . . . a 6
jointly or Qualifying
widow(er), 7a Other income from Schedule 1, line 9 . . . . . . . . . . . . . . . . . . . . 7a 0.
$24,400
• Head of b Add lines 1, 2b, 3b, 4b, 4d, 5b, 6, and 7a. This is your total income . . . . . . . . . . . a 7b 91,218.
household, 841.
$18,350
8a Adjustments to income from Schedule 1, line 22 . . . . . . . . . . . . . . . . . 8a
• If you checked b Subtract line 8a from line 7b. This is your adjusted gross income . . . . . . . . . . . a 8b 90,377.
any box under
Standard 9 Standard deduction or itemized deductions (from Schedule A) . . . . . 9 24,400.
Deduction, 10 Qualified business income deduction. Attach Form 8995 or Form 8995-A . . . 10
see instructions.
11a Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . 11a 24,400.
b Taxable income. Subtract line 11a from line 8b. If zero or less, enter -0- . . . . . . . . . . . 11b 65,977.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2019)
 Form 1040 (2019) Page 2
12a Tax (see inst.) Check if any from Form(s): 1 8814 2 4972 3 12a 7,529.
b Add Schedule 2, line 3, and line 12a and enter the total . . . . . . . . . . . . . . a 12b 7,529.
13a Child tax credit or credit for other dependents . . . . . . . . . . 13a 4,000.
b Add Schedule 3, line 7, and line 13a and enter the total . . . . . . . . . . . . . . a 13b 4,000.
14 Subtract line 13b from line 12b. If zero or less, enter -0- . . . . . . . . . . . . . . . 14 3,529.
15 Other taxes, including self-employment tax, from Schedule 2, line 10 . . . . . . . . . . . . 15 0.
16 Add lines 14 and 15. This is your total tax . . . . . . . . . . . . . . . . . . a 16 3,529.
17 Federal income tax withheld from Forms W-2 and 1099 . . . . . . . . . . . . . . . 17 9,833.
• If you have a
18 Other payments and refundable credits:
qualifying child, a Earned income credit (EIC) . . . . . . . . No
. . . . . . . 18a
attach Sch. EIC.
• If you have b Additional child tax credit. Attach Schedule 8812 . . . . . . . . . 18b
nontaxable c American opportunity credit from Form 8863, line 8 . . . . . . . . 18c
combat pay, see
instructions. d Schedule 3, line 14 . . . . . . . . . . . . . . . . . 18d
e Add lines 18a through 18d. These are your total other payments and refundable credits . . . . . a 18e
19 Add lines 17 and 18e. These are your total payments . . . . . . . . . . . . . . . a 19 9,833.
Refund 20 If line 19 is more than line 16, subtract line 16 from line 19. This is the amount you overpaid . . . . . . 20 6,304.
21a Amount of line 20 you want refunded to you. If Form 8888 is attached, check here . . . . . . a 21a 6,304.
Direct deposit? a b Routing number 0 4 1 0 0 0 1 2 4 a c Type: Checking Savings
See instructions.
a d Account number 4 2 3 8 9 5 2 4 4 8
22 Amount of line 20 you want applied to your 2020 estimated tax . . . . a 22
Amount 23 Amount you owe. Subtract line 19 from line 16. For details on how to pay, see instructions . . . . . a 23
You Owe 24 Estimated tax penalty (see instructions) . . . . . . . . . . . a 24
Third Party Do you want to allow another person (other than your paid preparer) to discuss this return with the IRS? See instructions. Yes. Complete below.
Designee No
(Other than Designee’s Phone Personal identification
paid preparer) name a no. a number (PIN) a

Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F

Joint return? maintenance (see inst.)

See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)
Certified Professional Coder
Phone no. Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid 3rd Party Designee
Preparer Self-employed
Firm’s name a Self-Prepared Phone no.
Use Only
Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 01/27/20 Intuit.cg.cfp.sp Form 1040 (2019)
SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
2019
(Form 1040 or 1040-SR)
a Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 01
Name(s) shown on Form 1040 or 1040-SR Your social security number
shawn E & barbara C chavis 246-23-6504
At any time during 2019, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any
virtual currency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . . . . 1 0.
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions) a
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . . . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Other income. List type and amount a
8
9 Combine lines 1 through 8. Enter here and on Form 1040 or 1040-SR, line 7a . . . . . . . . 9 0.
Part II Adjustments to Income
10 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach
Form 2106 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . . . . . 12
13 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . . . . . . 13
14 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . 14
15 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . . . 15
16 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . . . 16
17 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . . . . 17
18a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . . a
c Date of original divorce or separation agreement (see instructions) a
19 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . . . 20 841.
21 Tuition and fees. Attach Form 8917 . . . . . . . . . . . . . . . . . . . . . . 21
22 Add lines 10 through 21. These are your adjustments to income. Enter here and on Form 1040 or
1040-SR, line 8a . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 841.
For Paperwork Reduction Act Notice, see your tax return instructions. REV 01/27/20 Intuit.cg.cfp.sp Schedule 1 (Form 1040 or 1040-SR) 2019
Form 8995 Qualified Business Income Deduction OMB No. 1545-0123

Simplified Computation
a Attach
to your tax return.
2019
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form8995 for instructions and the latest information. Sequence No. 55
Name(s) shown on return Your taxpayer identification number
shawn E & barbara C chavis 246-23-6504

1 (a) Trade, business, or aggregation name (b) Taxpayer (c) Qualified business
identification number income or (loss)

ii

iii

iv

2 Total qualified business income or (loss). Combine lines 1i through 1v,

column (c) . . . . . . . . . . . . . . . . . . . . . . 2
3 Qualified business net (loss) carryforward from the prior year . . . . . . . 3
4 Total qualified business income. Combine lines 2 and 3. If zero or less, enter -0- 4
5 Qualified business income component. Multiply line 4 by 20% (0.20) . . . . . . . . . . . 5
6 Qualified REIT dividends and publicly traded partnership (PTP) income or (loss)
(see instructions) . . . . . . . . . . . . . . . . . . . . 6
7 Qualified REIT dividends and qualified PTP (loss) carryforward from the prior
year . . . . . . . . . . . . . . . . . . . . . . . . . 7 0.
8 Total qualified REIT dividends and PTP income. Combine lines 6 and 7. If zero
or less, enter -0- . . . . . . . . . . . . . . . . . . . . 8 0.
9 REIT and PTP component. Multiply line 8 by 20% (0.20) . . . . . . . . . . . . . . . 9 0.
10 Qualified business income deduction before the income limitation. Add lines 5 and 9 . . . . . . 10 0.
11 Taxable income before qualified business income deduction . . . . . . 11
12 Net capital gain (see instructions) . . . . . . . . . . . . . . . 12
13 Subtract line 12 from line 11. If zero or less, enter -0- . . . . . . . . 13 0.
14 Income limitation. Multiply line 13 by 20% (0.20) . . . . . . . . . . . . . . . . . . 14 0.
15 Qualified business income deduction. Enter the lesser of line 10 or line 14. Also enter this amount on
the applicable line of your return . . . . . . . . . . . . . . . . . . . . . . a 15 0.
16 Total qualified business (loss) carryforward. Combine lines 2 and 3. If greater than zero, enter -0- . . 16 0.
17 Total qualified REIT dividends and PTP (loss) carryforward. Combine lines 6 and 7. If greater than
zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 0.
For Privacy Act and Paperwork Reduction Act Notice, see instructions. REV 01/27/20 Intuit.cg.cfp.sp Form 8995 (2019)
Michigan Department of Treasury (Rev. 05-19), Page 1 of 2 Issued under authority of Public Act 281 of 1967, as amended.

2019 MICHIGAN Individual Income Tax Return MI-1040 Amended Return

(Include Schedule AMD)
Return is due April 15, 2020. Type or print in blue or black ink.
1. Filer’s First Name M.I. Last Name 2. Filer’s Full Social Security No. (Example: 123-45-6789)
SHAWN E CHAVIS
If a Joint Return, Spouse’s First Name M.I. Last Name
246 23 6504
BARBARA C CHAVIS 3. Spouse’s Full Social Security No. (Example: 123-45-6789)
Home Address (Number, Street, or P.O. Box)
885 LOCHAVEN RD 379 66 5351
City or Town State ZIP Code 4. School District Code (5 digits – see page 60)
WATERFORD MI 48327-3913 63300
5. STATE CAMPAIGN FUND 6. FARMERS, FISHERMEN, OR SEAFARERS
Check if you (and/or your spouse, if a. Filer
¿OLQJDMRLQWUHWXUQZDQWRI\RXUWD[HV Check this box if 2/3 of your income is from farming,
to go to this fund. This will not increase b. ¿VKLQJRUVHDIDULQJ
Spouse
your tax or reduce your refund.

7. 2019 FILING STATUS. Check one. 8. 2019 RESIDENCY STATUS. Check all that apply.
a. Single * If you check box “c,” complete a. X Resident
line 3 and enter spouse’s full name * If you check box “b” or
b. X 0DUULHG¿OLQJMRLQWO\ below: b. Nonresident * “c,” you must complete
and include Schedule
NR.
c. 0DUULHG¿OLQJVHSDUDWHO\ c. Part-Year Resident *

9. EXEMPTIONS. NOTE: If someone else can claim you as a dependent, check box 9eHQWHURQOLQHDDQGHQWHURQOLQH9e (see instr.).

a. Number of exemptions (see instructions) ............................................................. 9a. 4 x 4,400 9a. 17600 00

b. Number of individuals who qualify for one of the following special exemptions: deaf,
blind, hemiplegic, paraplegic, quadriplegic, or totally and permanently disabled 9b. x  9b. 00
c. 1XPEHURITXDOL¿HGGLVDEOHGYHWHUDQV ................................................................. 9c. x  9c. 00
d. 1XPEHURI&HUWL¿FDWHVRI6WLOOELUWKIURP0'++6VHHLQVWUXFWLRQV ..................... 9d. x  9d. 00

e. Claimed as dependent, see line 9 NOTE above .................................................. 9e. 9e. 00

f. Add lines 9a, 9b, 9c, 9d and 9e. Enter here and on line 15 ............................................................................. 9f. 17600 00

10. Adjusted Gross Income from your U.S. Forms 1040 or 1040NR (see instructions) ................................ 10. 90377 00

11. Additions from Schedule 1, line 9. Include Schedule 1 ............................................................................ 11. 00

12. Total. Add lines 10 and 11 .......................................................................................................................... 12. 90377 00

13. Subtractions from Schedule 1, line 28. Include Schedule 1 .................................................................... 13. 0 00

14. Income subject to tax. Subtract line 13 from line 12. If line 13 is greater than line 12, enter “0” ............ 14. 90377 00

15. Exemption allowance. Enter amount from line 9f or Schedule NR, line 19.............................................. 15. 17600 00

16. Taxable income. Subtract line 15 from line 14. If line 15 is greater than line 14, enter “0” ...................... 16. 72777 00

17. Tax. Multiply line 16 by 4.25% (0.0425) ..................................................................................................... 17. 3093 00

NON-REFUNDABLE CREDITS AMOUNT CREDIT

18. Income Tax Imposed by government units outside Michigan.

Include a copy of the return (see instructions)........................ 18a. 00 18b. 00
19. Michigan Historic Preservation Tax Credit carryforward (see
instructions) ............................................................................ 19a. 00 19b. 00
20. Income Tax. Subtract the sum of lines 18b and 19b from line 17.
If the sum of lines 18b and 19b is greater than line 17, enter “0” ............................................................... 20. 3093 00
REV 01/17/20 INTUIT.CG.CFP.SP
+ 1555 2019 05 01 27 5 Continue on page 2. This form cannot be processed if page 2 is not completed and included.
2019 MI-1040, Page 2 of 2
Filer’s Full Social Security Number 246 23 6504
21. Enter amount of Income Tax from line 20. .................................................................................................. 21. 3093 00
22. Voluntary Contributions from Form 4642, line 10. Include Form 4642...................................................... 22. 00
23. USE TAX. Use tax due on Internet, mail order or other out-of-state purchases from
Worksheet 1 (see instructions) ................................................................................................................... 23. 0 00

24. Total Tax Liability. Add lines 21, 22 and 23 ................................................................................... 24. 3093 00
REFUNDABLE CREDITS AND PAYMENTS

25. Property Tax Credit. Include MI-1040CR or MI-1040CR-2 ..................................................................... 25. 00

26. Farmland Preservation Tax Credit. Include MI-1040CR-5 ..................................................................... 26. 00

FEDERAL MICHIGAN

27. Earned Income Tax Credit. Multiply line 27a by 6% (0.06) and
enter result on line 27b. ........................................................... 27a. 00 27b. 00

28. Michigan Historic Preservation Tax Credit (refundable). Include Form 3581. ........................................... 28. 00

29. Michigan tax withheld from Schedule W, line 6. Include Schedule W (do not submit W-2s) ................. 29. 3877 00

30. Estimated tax, extension payments and 2018 credit forward ..................................................................... 30. 00
31. 2019 AMENDED RETURNS ONLY. Taxpayers completing an original 2019 return should skip to line 32.
Amended returns must include Schedule AMD (see instructions).

If you had a refund and/or credit forward on the original return, check box 31a and enter this amount as a
31a. negative number on line 31c.

If you paid with the original return, check box 31b and enter the amount paid with the original return, plus
31b. DQ\DGGLWLRQDOWD[SDLGDIWHU¿OLQJDVDSRVLWLYHQXPEHURQOLQHF'RQRWLQFOXGHLQWHUHVWRUSHQDOW\ 31c. 00

32. Total refundable credits and payments. Add lines 25, 26, 27b, 28, 29, 30 and 31c ........................ 32. 3877 00
REFUND OR TAX DUE
33. If line 32 is less than line 24, subtract line 32 from line 24. If applicable, see instructions.

Include interest 00 and penalty 00 ......................... YOU OWE 33. 00

34. Overpayment. If line 32 is greater than line 24, subtract line 24 from line 32 ................................ 34. 784 00

35. Credit Forward. Amount of line 34 to be credited to your 2020 estimated tax for your 2020 tax return ... 35. 00

36. Subtract line 35 from line 34. ...................................................................................... REFUND 36. 784 00
DIRECT DEPOSIT a. Routing Transit Number b. Account Number c. Type of Account
'HSRVLW\RXUUHIXQGGLUHFWO\WR\RXU¿QDQFLDO 1. X Checking 2. Savings
LQVWLWXWLRQ6HHLQVWUXFWLRQVDQGFRPSOHWHDE
DQGF 041000124 4238952448
Deceased Taxpayer. If Filer and/or Spouse died after December 31, 2018, enter dates below. 3UHSDUHU&HUWL¿FDWLRQ ,GHFODUHXQGHUSHQDOW\RISHUMXU\WKDW
ENTER DATE OF DEATH ONLY. Example: 04-15-2019 (MM-DD-YYYY) WKLVUHWXUQLVEDVHGRQDOOLQIRUPDWLRQRIZKLFK,KDYHDQ\NQRZOHGJH
Preparer’s PTIN, FEIN or SSN
Filer Spouse

Preparer’s Name (print or type)

7D[SD\HU&HUWL¿FDWLRQ ,GHFODUHXQGHUSHQDOW\RISHUMXU\WKDWWKHLQIRUPDWLRQLQWKLVUHWXUQ
DQGDWWDFKPHQWVLVWUXHDQGFRPSOHWHWRWKHEHVWRIP\NQRZOHGJH SELF-PREPARED
Filer’s Signature Date Preparer’s Business Name, Address and Telephone Number

Spouse’s Signature Date

By checking this box, I authorize Treasury to discuss my return with my preparer.

Refund, credit, or zero returns. Mail your return to: Michigan Department of Treasury, Lansing, MI 48956
Pay amount on line 33 (see instructions). Mail your check and return to: Michigan Department of Treasury, Lansing, MI 48929

+ 1555
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2019 05 02 27 3
Michigan Department of Treasury (Rev. 04-19), Page 1
Schedule W
2019 MICHIGAN Withholding Tax Schedule
Issued under authority of Public Act 281 of 1967, as amended.

Type or print in blue or black ink. Attachment 13

INSTRUCTIONS: If you had Michigan income tax withheld in 2019, you must complete a Withholding Tax Schedule (Schedule W) to claim the
withholding on your Individual Income Tax Return0,OLQH5HSRUWPLOLWDU\SD\LQ7DEOHDQGPLOLWDU\UHWLUHPHQWEHQH¿WVDQGWD[DEOH
UDLOURDGUHWLUHPHQWEHQH¿WVERWK7LHUDQG7LHULQ7DEOHHYHQLIQR0LFKLJDQWD[ZDVZLWKKHOG,QFOXGH\RXUFRPSOHWHG6FKHGXOH:ZLWK)RUP
MI-1040. See complete instructions on page 2 of this form. If you need additional space, include another Schedule W.
)LOHU¶V)LUVW1DPH M.I. /DVW1DPH )LOHU¶V)XOO6RFLDO6HFXULW\1R([DPSOH

SHAWN E CHAVIS 246 23 6504

,ID-RLQW5HWXUQ6SRXVH¶V)LUVW1DPH M.I. /DVW1DPH 6SRXVH¶V)XOO6RFLDO6HFXULW\1R([DPSOH

BARBARA C CHAVIS 379 66 5351

TABLE 1: MICHIGAN TAX WITHHELD OR MILITARY PAY REPORTED ON W-2, W-2G or CORRECTED W-2 FORMS
A B C D E
(QWHU³;´IRU (PSOR\HU¶VLGHQWL¿FDWLRQQXPEHU Box 1 — Wages, tips, Box 17 — Michigan
Filer or Spouse ([DPSOH %R[F²(PSOR\HU¶VQDPH other compensation income tax withheld

X 38-2177043 FULLER CENTRAL P 57200 00 2431 00

X 38-2993672 MICHIGAN HEART G 34018 00 1446 00

00 00

00 00

00 00

(QWHU7DEOH6XEWRWDOIURPDGGLWLRQDO6FKHGXOH:IRUPVLIDSSOLFDEOH ...................................................... 00

4. SUBTOTAL. (QWHUWRWDORI7DEOHFROXPQ( ............................................................................... 4. 3877 00

TABLE 2: MICHIGAN TAX WITHHELD OR MILITARY RETIREMENT BENEFITS AND RAILROAD RETIREMENT
BENEFITS (BOTH TIER 1 AND TIER 2) REPORTED ON 1099 FORMS
A B C D E
(QWHU³;´IRU 3D\HU¶VIHGHUDOLGHQWL¿FDWLRQ Taxable pension distribution, Michigan income
Filer or Spouse QXPEHU([DPSOH 3D\HU¶VQDPH misc. income, etc. (see inst.) tax withheld

00 00

00 00

00 00

00 00

00 00

(QWHU7DEOH6XEWRWDOIURPDGGLWLRQDO6FKHGXOH:IRUPVLIDSSOLFDEOH ...................................................... 00

 SUBTOTAL.(QWHUWRWDORI7DEOHFROXPQ( ...............................................................................  00

6. TOTAL.$GGOLQHVDQG(QWHUKHUHDQGFDUU\WR0,OLQH............................................ 6. 3877 00
REV 01/17/20 INTUIT.CG.CFP.SP

+ 1555 2019 57 01 27 6